Patient monitor for monitoring microcirculation

ABSTRACT

A patient monitor capable of measuring microcirculation at a tissue site includes a light source, a beam splitter, a photodetector and a patient monitor. Light emitted from the light source is split into a reference arm and a sample arm. The light in the sample arm is directed at a tissue site, such as an eyelid. The reflected light from the tissue site is interfered with the light from the reference arm. The photodetector measures the interference of the light from both the sample arm and the reference arm. The patient monitor uses the measurements from the photodetector to calculate the oxygen saturation at the tissue site and monitor the microcirculation at the tissue site.

CROSS-REFERENCE TO RELATED APPLICATIONS

Any and all applications, for which a foreign or domestic priority claimis identified in the Application Data Sheet as filed with the presentapplication, are hereby incorporated by reference. For example, thisapplication is a continuation of U.S. patent application Ser. No.14/746,446, filed Jun. 22, 2015, entitled “Patient Monitor ForMonitoring Microcirculation,” which is a continuation of U.S. patentapplication Ser. No. 13/369,773, filed Feb. 9, 2012, now issued as U.S.Pat. No. 9,066,666, entitled “Patient Monitor For MonitoringMicrocirculation,” which claims the benefit of U.S. Provisional PatentApplication No. 61/446,969, filed Feb. 25, 2011, entitled “PatientMonitor for Monitoring Microcirculation,” the entirety of each of whichis hereby incorporated herein by reference to be considered a part ofthis specification.

FIELD

The present disclosure relates to medical sensors and specifically to amedical sensor and/or monitor for determining the circulation state inblood vessels.

BACKGROUND OF THE DISCLOSURE

Patient monitoring of various physiological parameters of a patient isimportant to a wide range of medical applications. Oximetry is one ofthe techniques that has developed to accomplish the monitoring of someof these physiological characteristics. It was developed to study and tomeasure, among other things, the oxygen status of blood. Pulseoximetry—a noninvasive, widely accepted form of oximetry—relies on asensor attached externally to a patient to output signals indicative ofvarious physiological parameters, such as a patient's constituentsand/or analytes, including for example a percent value for arterialoxygen saturation, carbon monoxide saturation, methemoglobin saturation,fractional saturations, total hematocrit, bilirubins, perfusion quality,or the like. A pulse oximetry system generally includes a patientmonitor, a communications medium such as a cable, and/or a physiologicalsensor having light emitters and a detector, such as one or more LEDsand a photodetector. The sensor is attached to a tissue site, such as afinger, toe, ear lobe, nose, hand, foot, or other site having pulsatileblood flow which can be penetrated by light from the emitters. Thedetector is responsive to the emitted light after attenuation bypulsatile blood flowing in the tissue site. The detector outputs adetector signal to the monitor over the communication medium, whichprocesses the signal to provide a numerical readout of physiologicalparameters such as oxygen saturation (SpO2) and/or pulse rate. Thedetector signal can also be used by the monitor to create an image on adisplay screen of the tissue being monitored.

High fidelity pulse oximeters capable of reading through motion inducednoise are disclosed in U.S. Pat. Nos. 7,096,054, 6,813,511, 6,792,300,6,770,028, 6,658,276, 6,157,850, 6,002,952 5,769,785, and 5,758,644,which are assigned to Masimo Corporation of Irvine, Calif. (“MasimoCorp.”) and are incorporated by reference herein. Advanced physiologicalmonitoring systems can incorporate pulse oximetry in addition toadvanced features for the calculation and display of other bloodparameters, such as carboxyhemoglobin (HbCO), methemoglobin (HbMet),total hemoglobin (Hbt), total Hematocrit (Hct), oxygen concentrations,glucose concentrations, blood pressure, electrocardiogram data,temperature, and/or respiratory rate as a few examples. Typically, thephysiological monitoring system provides a numerical readout of and/orwaveform of the measured parameter. Advanced physiological monitors andmultiple wavelength optical sensors capable of measuring parameters inaddition to SpO2, such as HbCO, HbMet and/or Hbt are described in atleast U.S. Pat. No. 7,764,982, and U.S. application Ser. No. 11/366,208,filed Mar. 1, 2006, titled Noninvasive Multi-Parameter Patient Monitor,assigned to Masimo Laboratories, Inc. and incorporated by referenceherein. Further, noninvasive blood parameter monitors and opticalsensors including Rainbow™ adhesive and reusable sensors and RAD-57™ andRadical-7™ monitors capable of measuring SpO2, pulse rate, perfusionindex (PI), signal quality (SiQ), pulse variability index (PVI), HbCOand/or HbMet, among other parameters, are also commercially availablefrom Masimo Corp.

During blood circulation, arteries carry blood away from the heart inhigh volume and under high pressure. Arteries branch off into smallerblood vessels, called arterioles. Arterioles are well innervated,surrounded by smooth muscle cells, and are about 10-100 μm in diameter.Arterioles carry the blood to the capillaries, which are the smallestblood vessels, which are not innervated, have no smooth muscle, and areabout 5-8 μm in diameter. Blood flows out of the capillaries into thevenules, which have little smooth muscle and are about 10-200 μm indiameter. The blood flows from venules into the veins, which carry bloodback to the heart. Arterioles, venules, and/or capillaries may also bereferred to as microvessels.

Microcirculation generally refers to the vascular network lying betweenthe arterioles and the venules, including the capillaries, as well asthe flow of blood through this network. These small vessels can be foundin the vasculature which are embedded within organs and are responsiblefor the distribution of blood within tissues as opposed to largervessels in the macrocirculation which transport blood to and from theorgans. One of the functions of microcirculation is to deliver oxygenand other nutrients to tissue. Sometimes, microcirculation in thesesmall vessels can become blocked, interfering with the delivery ofoxygen to the tissue.

SUMMARY

As placement of a physiological monitoring sensor is typically at asensor site located at an extremity of the body, the state ofmicrocirculation, such as whether vessels are blocked or open, can havea significant effect on the readings at the sensor site. It is thereforedesirable to provide a patient monitor and/or physiological monitoringsensor capable of distinguishing the microcirculation state of bloodvessels. In some embodiments, the patient monitor and/or sensor providea warning and/or compensates a measurement based on the microcirculationstate. In some embodiments, a microcirculation determination processimplementable by the patient monitor and/or sensor is used to determinethe state of microcirculation of the patient.

BRIEF DESCRIPTION OF THE DRAWINGS

Throughout the drawings, reference numbers may be re-used to indicatecorrespondence between referenced elements. The drawings are provided toillustrate embodiments of the disclosure described herein and not tolimit the scope thereof.

FIG. 1 illustrates a block diagram of a patient monitor, such as a pulseoximeter, and associated sensor;

FIG. 2A is a schematic block diagram of a microcirculation monitoringdevice

FIG. 2B is a block illustrating an eyelid being monitored by amicrocirculation monitoring device.

FIG. 3 illustrates a flow diagram for a process for determining thestate of microcirculation usable by a pulse oximeter; and

FIG. 4 illustrates a flow diagram for a process for determining thestate of microcirculation wherein multiple data points are collected.

DETAILED DESCRIPTION

FIG. 1 illustrates a block diagram of a patient monitor 100, such as amicrocirculation monitoring device, and associated non-invasive sensor110. Generally, in the case of a microcirculation monitoring device, thesensor 110 has a light source 112 and a photodiode detector 114. In oneembodiment, the light source 112 includes two LED emitters, generallyone at a red wavelength and one at an infrared wavelength. In anotherembodiment, the light source 112 includes one light emitter that emitslight at multiple wavelengths and a collimator and spectral filter. Thesensor 110 can be attached to a patient in a number of differentlocations including a finger, an ear, an arm, a leg, a toe, a cheek, alip, a tongue, a forehead, or an eyelid.

Typically, non-invasive sensors are attached to a finger, ear, foreheador cheek or other extremity. However, these locations can have a numberof drawbacks. For example, signals measured at the ear can be very weakcompared to other sites. In addition, cold temperatures can lead to poorperfusion at the ear. In some instances, the signal may be so weak thata non-invasive measurement is not feasible.

A non-invasive sensor placed at the finger can also have a number ofdisadvantages. Similar, to the ear, cold temperatures, or a coldpatient, may result in poor perfusion at the finger. In addition, apatient experiencing shock may experience poor perfusion in the finger,as blood is directed away from the extremities and to the body's coreduring shock. Patient movement can also make it difficult to obtainaccurate non-invasive readings at the finger.

Despite the disadvantages of measuring at fingers and ears, measuringoxygen saturation and monitoring microcirculation at the eyelid has anumber of advantages. For example, similar to other parts of the head,the eyelids are generally well perfused. In addition, lower temperaturesare less likely to effect perfusion in the eyelid than in the ear orfinger. Furthermore, there is less likely to be patient movement at theeyelid than at a finger, resulting in more accurate readings. Inaddition, placement of a sensor on the head during surgery can decreasethe probability of a cable obstructing access to the patient. Thethickness of the eyelid (approximately 1 mm) can also be of benefit whenusing Optical Coherence Tomography (OCT) devices.

For an eyelid, the sensor 110 is configured so that the light source 112projects light into the microvessels of the eyelid. The light source 112is activated by drive signals 122 from the patient monitor 100. Thelight entering the tissue is either absorbed, reflected, or refracted.After being reflected, some of the light returns in a direction that issubstantially opposite from the direction it entered. The detector 114is positioned in such a way so as to detect the reflected light as itemerges from the eyelid tissues. The detector 114 generates a signal124, which is relayed by a cable or other means to the patient monitor100.

In one embodiment, the patient monitor 100 can include a pulse oximeterto determine oxygen saturation (SpO2) by computing the differentialabsorption by arterial blood of the two wavelengths emitted by the LEDemitters of the light source 112. Additional information regarding theuse of a pulse oximeter can be found in U.S. application Ser. No.13/101,093, entitled “Patient Monitor for Determining MicrocirculationState,” filed May 4, 2011, and U.S. Pat. No. 7,356,365, issued Apr. 8,2008, entitled “Method and Apparatus for Tissue Oximetry,” both of whichare hereby incorporated by reference in their entirety. The patientmonitor can further include a sensor interface 120, one or moreprocessors 130, such as a microcirculation processor, an instrumentmanager 140, a display 150, an audible indicator (tone generator) 160,and a keypad 170. The sensor interface 120 provides a light source drivecurrent 122 which drives the light source 112. The sensor interface 120also has input circuitry for amplification and filtering of the signal124 generated by the photodiode detector 114, which corresponds to thelight detected from the tissue after having been reflected and/orrefracted by the eyelid. The microcirculation processor 130 calculatesmicrocirculation states of the microvessels in the eyelid tissue, aswill be described in greater detail below, and can also calculate theoxygen saturation, as described in greater detail in U.S. applicationSer. No. 13/101,093 and U.S. Pat. No. 7,356,365, previously incorporatedby reference in their entirety. The instrument manager 140 provideshardware and software interfaces for managing the display 150, audibleindicator 160, and keypad 170. The display 150 shows the computed oxygensaturation status, as described above, as well as the microcirculationstatus. The display 150 can also show an image of the microvessel.Similarly, other patient parameters including HbCO, HbMet, Hbt, Hct,oxygen concentrations, glucose concentrations, pulse rate, PI, SiQ,and/or PVI can be computed, as described in greater detail in U.S.application Ser. No. 13/101,093 and U.S. Pat. No. 7,356,365. The audibleindicator 160 provides the pulse beep as well as alarms indicatingdesaturation and microcirculation events. The keypad 170 provides a userinterface for such things as alarm thresholds, alarm enablement, and/ordisplay options.

Computation of SpO2 relies on the differential light absorption ofoxygenated hemoglobin, HbO₂, and deoxygenated hemoglobin, Hb, todetermine their respective concentrations in the arterial blood.Specifically, pulse oximetry measurements are made at red (R) andinfrared (IR) wavelengths chosen such that deoxygenated hemoglobinabsorbs more red light than oxygenated hemoglobin, and, conversely,oxygenated hemoglobin absorbs more infrared light than deoxygenatedhemoglobin, for example 660 nm (R) and 905 nm (IR).

To distinguish between tissue absorption at the two wavelengths, in someembodiments, the red and infrared emitters of the light source 112 areprovided drive current 122 so that only one is emitting light at a giventime. For example, the emitters can be cycled on and off alternately, insequence, with each only active for a quarter cycle and with a quartercycle separating the active times. This allows for separation of red andinfrared signals and removal of ambient light levels by downstreamsignal processing. Because only a single detector 114 is used, itresponds to both the red and infrared emitted light and generates atime-division-multiplexed (“modulated”) output signal 124. Thismodulated signal 124 is coupled to the input of the sensor interface120.

In addition to the differential absorption of hemoglobin derivatives,pulse oximetry relies on the pulsatile nature of arterial blood todifferentiate hemoglobin absorption from absorption of otherconstituents in the surrounding tissues. Light absorption betweensystole and diastole varies due to the blood volume change from theinflow and outflow of arterial blood at a peripheral tissue site. Thistissue site might also comprise skin, muscle, bone, venous blood, fat,pigment, and/or the like, each of which absorbs light. It is assumedthat the background absorption due to these surrounding tissues isinvariant and can be ignored. Thus, blood oxygen saturation measurementsare based upon a ratio of the time-varying or AC portion of the detectedred and infrared signals with respect to the time-invariant or DCportion: R/IR=(Red_(AC)/Red_(DC))/(IR_(AC)/IR_(DC)).

The desired SpO2 measurement is then computed from this ratio. Therelationship between R/IR and SpO2 can be determined by statisticalregression of experimental measurements obtained from human volunteersand calibrated measurements of oxygen saturation. In a pulse oximeterdevice, this empirical relationship can be stored as a “calibrationcurve” in a read-only memory (ROM) look-up table so that SpO2 can bedirectly read-out of the memory in response to input R/IR measurements.

The patient monitor 100 can also measure perfusion index, PI, which is anumerical value that indicates the strength of the IR signal returnedfrom a monitoring site and provides a relative assessment of the pulsestrength at the monitoring site. The perfusion index can be defined asfollows: PI=(IR_(max)−IR_(min))/IR_(DC), where IR_(max) is the maximumvalue, IR_(min) is the minimum value, and IR_(DC) is the average valueof the invariant portion. As the light absorption characteristic ofblood is typically “flatter” or less sensitive to oxygen saturationaround the infrared wavelength, the infrared signal from a sensor isinfluenced primarily by the amount of the blood at the monitoring site,not by the level of oxygenation in the blood. Accordingly, the perfusionindex, which is a numerical value that indicates the strength of the IRsignal returned from a monitoring site, provides a relative assessmentof the pulse strength at the monitoring site. PI values generally rangefrom 0.02% (very weak pulse strength) to 20% (very strong pulsestrength). In some embodiments, PI can be measured using otherwavelengths. For example, red, near red, near IR, as well as otherwavelengths can be used.

In an embodiment, the sensor 110 also includes a memory device 116. Thememory 116 can include any one or more of a wide variety of memorydevices known to an artisan from the disclosure herein, includingerasable programmable read-only memory (EPROM), electrically erasableprogrammable read-only memory (EEPROM), flash memory, other non-volatilememory, a combination of the same, or the like. The memory 116 caninclude a read-only device such as read-only memory (ROM), a read andwrite device such as random-access memory (RAM), combinations of thesame, or the like. The remainder of the present disclosure will refer tosuch combination as simply EPROM for ease of disclosure; however, anartisan will recognize from the disclosure herein that the memory caninclude the ROM, the RAM, single wire memory, other types of memory,combinations of the same, or the like.

The memory device can advantageously store some or all of a wide varietydata and information, including, for example, information on the type oroperation of the sensor, type of patient or body tissue, buyer ormanufacturer information, sensor characteristics including the number ofwavelengths capable of being emitted, emitter specifications, emitterdrive requirements, demodulation data, calculation mode data,calibration data, software such as scripts, executable code, or thelike, sensor electronic elements, sensor life data indicating whethersome or all sensor components have expired and should be replaced,encryption information, monitor or algorithm upgrade instructions ordata, or the like. In an embodiment, the memory device can also includeoxygen saturation to perfusion index and R/IR ratio to perfusion indexratios and/or data.

In certain situations, pulse oximetry sensors may produce anomalousreadings, such as when a patient suffers from cyanosis. In a patientsuffering from cyanosis, blood cells are uncharacteristically low onoxygen, leading to oxygen deficiency and giving the patient's skin abluish-hue. One potential cause is that the patient's body produces toomuch hemoglobin, making the blood “thicker” or slower flowing, makingmicrovessels more prone to blockage. Thus, a “blocked” microcirculationstate can indicate cyanosis.

A “blocked” microcirculation state can also indicate other medicalconditions, such as sepsis, systemic inflammatory response syndrome(SIRS), or septicemia. Sepsis is a potentially deadly medical conditionthat is characterized by a whole-body inflammatory state (called SIRS)and the presence of a known or suspected infection. The body may developthis inflammatory response by the immune system to microbes in theblood, urine, lungs, skin, or other tissue. Septicemia is a relatedmedical term referring to the presence of pathogenic organisms in thebloodstream, which can lead to sepsis. Sepsis can also be referred to asblood poisoning. During sepsis or SIRS, inflammation in the body cancause constriction in blood vessels, leading to low blood pressure orinsufficient blood flow.

During a “blocked” microcirculation state, blood cells can get blockedin the microvessels, such as the arterioles and capillaries. Blood cellscan clump together or otherwise catch against the wall of blood vessels,creating a blockage that prevents blood cells, including red blood cellscarrying hemoglobin, from passing through the blockage. However, plasma,which is composed of mostly water and in which the blood cells aresuspended, is generally able to flow through passages in the blockage.In some situations, some blood vessels at the monitoring site maycontinue to have normal flow while some vessels are blocked. Thus, a“blocked” microcirculation state can indicate that some microvessels inan area are blocked and not necessarily all vessels in the area areblocked.

With the blockage preventing most or all the red blood cells frompassing a blood vessel, at most only a limited amount of hemoglobinpasses through a blocked blood vessel. In some situations, the bloodvessel may only be partially blocked, where some hemoglobin passesthrough but less than when the blood vessel is unblocked. Normally,blood is made up of about 40-50% of red blood cells, of which about 95%is hemoglobin. Plasma, which is about 95% water, normally constitutesabout 55% of the blood's volume.

Accordingly, a pulse oximeter sensor placed on a tissue siteexperiencing blockage in microcirculation vessels may detect mostlyplasma passing through with no or only a small percentage of red bloodcells, at least at part of the monitoring site. The resulting change inthe normal composition of blood can cause anomalous readings in thepatient monitor. As plasma has generally different absorptioncharacteristics for red and infrared wavelengths than normal blood,pulse oximetry readings may become skewed. Red_(AC) and/or IR_(AC) canbe affected, causing measured R/IR ratio to change. For example, ifRed_(AC) rises or IR_(AC) drops, the R/IR ratio increases.Alternatively, if Red_(AC) drops or IR_(AC) rises, the R/IR ratiodecreases. Thus, the value of R/IR can change due to a change in thelight absorption of blood even if the underlying oxygen saturation ofthe blood remains the same.

However, by comparing oxygen saturation and PI for normalmicrocirculation to the oxygen saturation and PI for blockedmicrocirculation, such as by calculating and comparing ratios, themonitor can determine the existence of an abnormal situation. Typically,SpO2 is mostly independent of PI, with SpO2 varying minimally as PIincreases. However, SpO2 varying by more than normal as PI increases canindicate an anomalous microcirculation state, such as a blockage. In oneembodiment, by analyzing the measured ratios, the patient monitor 100can determine the microcirculation state, such as whether a blockedvessel exists in the microvessels. Alternatively, multiple measurementsof movement through the microvessels, such as the capillaries, can beused to determine the microcirculation state. For example, detectedmovement that is slower than normal can indicate blockage.

FIG. 2A is a schematic block diagram of a microcirculation monitoringdevice 200, which is described in greater detail in U.S. Pat. No.7,356,365, previously incorporated by reference. The monitoring device200 includes a light source 202, beam splitter 204, sample arm 206,imaging optics 208 in close proximity to the tissue 210, a reference arm212, a reflector 214, a photodetector 216 and a patient monitor 218.

As described in greater detail in U.S. Pat. No. 7,356,365, the lightsource 202 can emit light having an approximately equal wavelength, aspectrum of wavelengths, or a few different wavelengths, e.g., two. Thewavelengths can be selected based on the absorption spectrum ofoxygenated hemoglobin and deoxygenated hemoglobin. For example, peakabsorption for a oxygenated hemoglobin is approximately 940 nm and peakabsorption for a deoxygenated hemoglobin is approximately 660 nm. Thus,wavelengths of 660 nm and 940 nm can be used. The light from the lightsource 202 is split by a beam splitter 204 between a sample arm 206 anda reference arm 212. Reflected signals from arms 206 and 212 interfereand are presented to photodetector 216 for measurement. Preferably, theend of the sample arm 206 can contain imaging optics 208 to tailor thespot size according to the tissue being measured. The imaging optics 208can provide high coupling efficiency between the optical system and thetissue.

The tissue volume with which the light interacts (referred to as theinteraction volume) is determined by the spot size of the imaging optics(surface area) and the coherence length of the light (depth). Referencearm 212 of the interferometer determines the phase shift applied to thereference beam which in turn determines which reflected light from thesample will constructively interfere with the shifted reference beam.Thus, the reference arm 212 determines the depth within the interactionvolume from which scattered light is measured. The sample arm 206 canhave either a fixed or scanning reflector 214 (such as a mirror). Thiscan allow for a fixed sensor depth, adjustable sensor depth, or scan ofmultiple depths within the tissue.

The photodetector 216 measures the interference of the light from boththe sample arm 206 and the reference arm 212. The patient monitor 218uses the measured constructively interfered light at the differentwavelengths to provide a measurement of the oxygen saturation, PI, andto monitor the microcirculation. Microcirculation measurements can alsobe calculated by obtaining multiple images of the tissue site andanalyzing the movement of blood cells between the images.

FIG. 2B illustrates a block drawing of an eyelid being monitored by amicrocirculation monitoring device 200. As illustrated, light beams 250from a light source 202 (FIG. 2A) are split using the beam splitter 204into reference arm light beams 252 and sample arm light beams 254. Afterthe light beams 250 are split, the reference arm light beams 252 traveldown the reference arm 212 (FIG. 2A) to interact with the reflector 214(FIG. 2A), and the sample arm light beams 254 travel down the sample arm206 (FIG. 2A) to interact with the tissue from the upper eyelid 256.Although illustrated as interacting with the upper eyelid 256, it is tobe understood that the lower eyelid 258 can also be used.

The upper eyelid 256 either absorbs, reflects and/or refracts the samplearm light beams 254. Some of the sample arm light beams 254 arereflected back to the beam splitter 212. The beam splitter 212 directsat least some of the reflected sample arm light beams 254 to thedetector 216 (FIG. 2A).

The light beams traveling down the reference arm 212 (FIG. 2A) interactwith a reflector 214 (FIG. 2A) and are reflected back to the beamsplitter 212. Similar to the reflected sample arm light beams 254, thereflected reference arm light beams 256 are also directed to thedetector 216 by the beam splitter 212. As discussed above, a patientmonitor 200 (FIG. 2A) uses the detected signals obtained from theinterference of the reflected sample arm light beams 254 and thereflected reference arm light beams 252 to calculate oxygen saturation,perfusion index and other physiological parameters. The patient monitor200 (FIG. 2A) can also use the signals obtained from the detector 216 tomonitor microcirculation in the eyelid. The microcirculation states canbe monitored by comparing ratios of oxygen saturation and PI, asdescribed in greater detail below, or comparing images obtained of themicrovessels, as described above. If the microcirculation falls below apredetermined threshold, an alarm can be activated.

Although not illustrated in FIG. 2B, imaging optics 208 can also be usedto focus the sample arm light beams 254 prior to interacting with theeyelids. Furthermore, the end of the sample arm 206 and imaging optics208 can be placed in close proximity to the eyelid. In an embodiment,when a patient is unconscious, such as during a surgery, the end of thesample arm 206 and imaging optics 208 can be secured to the patientusing an adhesive. The adhesive can attach to the patient's face, suchas the cheek, forehead, ear or nose. Alternatively, the end of thesample arm 206 and imaging optics 208 can be fixedly attached to a pairof glasses or other device configured to cover a patient's eyes. Theglasses or other device can be placed on the patient such that thesample arm light beams 254 interact with the eyelid tissue. The glassesor other placement device can be specially configured to ensure that theproper distance between the eyelid and the sample arm 206 and imagingoptics 208 is achieved. The reference arm 212 and reflector 214 areconfigured and appropriate wavelength and polarization selected suchthat the appropriate depth of the eyelid tissue is measured.

Alternative designs can be used to monitor the microcirculation in aneyelid. For example, multiple images of a microvessel can be used tomonitor the microcirculation. The images can be obtained using OpticalCoherence Tomography (OCT), as is well known in the art. One method ofobtaining images of microvessels is described in greater detail in U.S.application Ser. No. 11/524,866, entitled “Microcirculation Imaging.”For example, a light source can output a beam of light having a broadspectrum of wavelengths. The beam of light can be collimated and passthrough a spectral filter, and a beam splitter can split the light suchthat a beam of light having approximately one wavelength is directedtowards microvessels of the eyelid. The light can be either polarized ornon-polarized. A polarizer located on one edge of the beam splitter canpolarize the light linearly, elliptically, or circularly, as desired.The wavelength and polarization of the light can be selected based onthe desired measurement depth. The wavelength and polarization of thelight can be altered using the spectral filter and/or polarizer. In oneembodiment, the wavelength can be between 420 and 810 nm. In anotherembodiment, the wavelength can be in the light green spectrum (525-575nm). The reflected light from the eyelid can be collected using aconverging lens and a photodetector. A processor can use the signalsfrom the photodetector to render an image of the eyelid tissue, ormicrovessels. Multiple images of the microvessels can be used tocalculate the velocity of the microcirculation and detect blockage. Forexample, the distance traveled by the blood cells between measurementscan be compared with the time between measurements to calculatevelocity. If the velocity is below a certain threshold an alarm can beactivated.

Other OCT methods can also be used to obtain images of the microvesselsof the eyelid or other tissue. For example, multiple light emittersemitting different wavelengths of light can be used to obtain an image.Multiple images of the eyelid tissue can then be used by a patientmonitor to calculate the velocity of the blood passing through thetissue, thereby monitoring the microcirculation of the eyelid.

FIG. 3 illustrates a flow diagram for a process 300 for determining thestate of microcirculation usable by a pulse oximeter. Microcirculationstate can be determined by comparison with microcirculation data storedon a patient monitor, such as the patient monitor 100 of FIG. 1. Theprocess 300 can be implemented by embodiments of the sensor 110 and/orpatient monitor 100 of FIG. 1 or other suitable device.

While in conventional pulse oximetry, measurements are generally takenpulse-by-pulse and averaged over pulses, microcirculation measurementscan be measured using only a single pulse or a portion of a singlepulse. This can be done, for example, at the minimum and/or maximumblood flow of a pulse. Microcirculation measurements can also bedetermined over multiple pulses. In some embodiments, microcirculationmeasurements are taken during a portion of the normal measurement timeused by a physiological sensor to take a measurement of a parameter,thereby allowing detection of aberrant parameter measurements using themicrocirculation measurements. For example, while a pulse oximeter ismeasuring SpO2 over several pulses, microcirculation measurements can betaken per pulse and a warning given if an irregular microcirculationstate is detected, thereby notifying a user of a possible aberration inthe current SpO2 reading.

At block 310, oxygen saturation is measured at a tissue monitoring site.In one embodiment, oxygen saturation is determined using a pulseoximeter sensor.

At block 320, perfusion index or pulse strength is measured. In oneembodiment, the perfusion index is determined using the same sensor usedto measure oxygen saturation so that readings are taken at the samemonitoring site.

At block 330, a ratio of oxygen saturation to perfusion index isdetermined. Oxygen saturation can be a SpO2 value based on the measuredR/IR ratio looked-up against a calibration curve. Alternatively, theratio can be perfusion index to oxygen saturation. In other embodiments,the measured R/IR ratio can be used directly instead of SpO2.

In some embodiments, multiple readings of perfusion index and oxygensaturation can be taken and averaged together before determining theratio in order to account for outliers. The multiple readings can befiltered before averaging. For example, readings can first be filteredbased on closeness of PI values before the readings are averagedtogether.

At block 340, the determined ratio in block 330 is compared to storedmicrocirculation data. The stored data can be data sets formicrocirculation states. In some embodiments, a ratio, a curve, a line,table, data points, or formula can be stored that corresponds to a dataset. The measured perfusion index and oxygen saturation can then becompared to the stored data. In some embodiments, multiple readings aretaken and a best fit line or curve is generated and compared to a storedbest fit line or curve. In some embodiments, readings are collected atvarious PI values in order to generate a trend line.

At block 350, the microcirculation state is determined from comparisonof the stored microcirculation data. For example, if the determinedratio is similar to a stored ratio corresponding to a data set forunblocked microcirculation, the microcirculation state is determined tobe unblocked. Other data sets for other microcirculation states, such asblocked and/or partially blocked can also be stored. Where multiple datasets are stored, the state can be determined by selecting the statecorresponding to the stored ratio closest to the measured ratio.

At block 360, the monitor can optionally generate an alarm and/ordisplay the microcirculation state. For example, an alarm signal and/oricon can be generated by the monitor to indicate that the readings maybe anomalous, such as when a blocked or partially blockedmicrocirculation state is detected. The alarm can be a visual indicator(e.g., icon, message or image) and/or an audio indicator. In anembodiment, the alarm can indicate the detection of cyanosis, sepsis,SIRS or other medical condition based at least partly on the determinedmicrocirculation state. In some embodiments, no action is taken, such aswhen readings are determined to be normal or non-threatening.

At block 370, the monitor can optionally compensate for themicrocirculation state in order to improve accuracy of the readings.After the microcirculation state returns to normal, the compensationprocess can be ended.

In one embodiment, an offset can be added to the measured parametervalue, such as SpO2. The offset can be calculated based on data sets formicrocirculation state. Different microcirculation states can havedifferent offsets. For example, if a “blocked” microcirculation stateproduces high readings for low PI values, a negative offset can be used.However, if a “blocked” state produces a low value for high PI values,then a positive offset can be used. In one embodiment, a varying offsetcan be used depending on the value of PI.

In one embodiment, a different wavelength emitter can be used tocompensate for a microcirculation state. For example, rather than usinga regular infrared emitter, typically 905 nm, an emitter with adifferent infrared wavelength, such as 970 nm can be used. In oneembodiment, the different wavelength is selected such that thewavelength is at a “flat” section of the light absorption curve forplasma, that is, where the light absorption is not much affected bychanges in oxygen saturation, as described in greater detail in U.S.application Ser. No. 13/101,093. In one embodiment, the selectedwavelength with regards to plasma mimics the properties of the regularwavelength with regards to normal flowing blood. In some embodiments, adifferent wavelength red emitter can be used instead of the regular redwavelength emitter.

In some embodiments, the pulse oximeter sensor used to measure oxygensaturation and PI can be provided with an additional emitter at adifferent wavelength than the existing emitters. When a certainmicrocirculation state is detected, such as a “blocked” state, theadditional emitter can be used. For example, a pulse oximetry sensor canbe equipped with LED's capable of emitting at 660 nm, 905 nm, and at 970nm wavelengths. Under normal operation, the 660 nm and 905 nm emittersare active. However, upon detecting a blocked microcirculation state,the 905 nm emitter can be deactivated and the 970 nm emitter activatedin its place. In some embodiments, a variable wavelength emitter can beused rather than separate emitters. In some embodiments, the additionalemitter can be a red wavelength emitter.

FIG. 4 illustrates a flow diagram for a process 400 for determining thestate of microcirculation wherein multiple data points are collected.The process 400 can be implemented by embodiments of the sensor 110and/or patient monitor 100 of FIG. 1 or other suitable device.

At block 410 and block 420, oxygen saturation and perfusion index aremeasured. At block 425, measured values are stored in memory. Eachpaired measurement forms a data point.

At block 430, the number of stored data points is checked to determineif sufficient data has been collected to determine the microcirculationstate. Data can be sufficient if a set number of data points have beencollected, a set amount of time has passed, and/or a spectrum of datapoints have been collected, such as for differing values of PI.

At block 440, the stored measured data is compared with storedmicrocirculation data. Typically, the microcirculation data ispre-stored on the pulse oximeter before use, as opposed to collectedduring use. A comparison can involve generating a curve or line from themeasured data, calculating a rate of change for the stored data,generating a trend line for the measured data or the like and comparingwith the stored microcirculation data.

At block 450, the microcirculation state is determined from comparisonof the stored microcirculation data. For example, if the measured datais similar to microcirculation data corresponding to a data set forunblocked microcirculation, the microcirculation state is determined tobe unblocked. Other data sets for other microcirculation states, such asfor blocked and/or partially blocked can also be stored. Where multipledata sets are stored, the state can be determined by selecting the statecorresponding to the stored ratio closest to the measured ratio.

Blocks 460 and 470 are similar to steps 360 and 370 described in FIG. 3.

As will be apparent from the above description, the R/IR ratiocorresponds to oxygen saturation or SpO2 and can be used in place ofoxygen saturation or SpO2 for the above comparisons, and vice versa.

While the above systems and methods have been described in terms ofoxygen saturation and PI, other physiological parameters can be measuredin place of or in addition to oxygen saturation and/or perfusion indexand used to determine microcirculation state. For example, perfusionindex is an indication of amplitude and/or signal strength and otherparameters or measurements indicating amplitude and/or signal strengthcan be used. In some embodiments, one or more different sensors can beused in place of or in addition to a pulse oximeter sensor.

In another embodiment, the microcirculation state can be calculatedwithout calculating oxygen saturation. For example, using OCT, asdescribed above, multiple measurements of the movement of blood withinthe microvessels can be taken. The multiple measurements can then becompared to determine the velocity of the blood traveling through themicrovessels. For example, the distance traveled by the blood betweenmeasurements can be compared with the time between measurements tocalculate velocity. In one embodiment, images of the microvessels areused to measure the movement of blood in the microvessels.

Conditional language used herein, such as, among others, “can,” “could,”“might,” “may,” “e.g.,” and the like, unless specifically statedotherwise, or otherwise understood within the context as used, isgenerally intended to convey that certain embodiments include, whileother embodiments do not include, certain features, elements and/orstates. Thus, such conditional language is not generally intended toimply that features, elements and/or states are in any way required forone or more embodiments or that one or more embodiments necessarilyinclude logic for deciding, with or without author input or prompting,whether these features, elements and/or states are included or are to beperformed in any particular embodiment. The terms “comprising,”“including,” “having,” and the like are synonymous and are usedinclusively, in an open-ended fashion, and do not exclude additionalelements, features, acts, operations, and so forth. Also, the term “or”is used in its inclusive sense (and not in its exclusive sense) so thatwhen used, for example, to connect a list of elements, the term “or”means one, some, or all of the elements in the list.

Various systems and processes for determining microcirculation eventshave been disclosed in detail in connection with various embodiments.These embodiments are disclosed by way of examples only and are not tolimit the scope of the claims that follow. Indeed, the novel methods andsystems described herein can be embodied in a variety of other forms;furthermore, various omissions, substitutions and changes in the form ofthe methods and systems described herein can be made without departingfrom the spirit of the inventions disclosed herein. The claims and theirequivalents are intended to cover such forms or modifications as wouldfall within the scope and spirit of certain of the inventions disclosedherein. One of ordinary skill in the art will appreciate the manyvariations, modifications and combinations. For example, the variousembodiments of the microcirculation determination process can be usedwith oxygen saturation sensors and with both disposable and reusablesensors. In some embodiments, the determination process can be appliedto other blood vessels to detect a blockage, even in vessels notinvolved in microcirculation.

Furthermore, in certain embodiments, the systems and methods describedherein can advantageously be implemented using computer software,hardware, firmware, or any combination of software, hardware, andfirmware. In one embodiment, the system includes a number of softwaremodules that comprise computer executable code for performing thefunctions described herein. In certain embodiments, thecomputer-executable code is executed on one or more general purposecomputers or processors. However, a skilled artisan will appreciate, inlight of this disclosure, that any module that can be implemented usingsoftware can also be implemented using a different combination ofhardware, software or firmware. For example, such a module can beimplemented completely in hardware using a combination of integratedcircuits. Alternatively or additionally, such a module can beimplemented completely or partially using specialized computers orprocessors designed to perform the particular functions described hereinrather than by general purpose computers or processors.

Moreover, certain embodiments of the invention are described withreference to methods, apparatus (systems) and computer program productsthat can be implemented by computer program instructions. These computerprogram instructions can be provided to a processor of a general purposecomputer, special purpose computer, or other programmable dataprocessing apparatus to produce a machine, such that the instructions,which execute via the processor of the computer or other programmabledata processing apparatus, create means for implementing the actsspecified herein to transform data from a first state to a second state.

Each of the processes, methods, and algorithms described in thepreceding sections may be embodied in, and fully or partially automatedby, code modules executed by one or more computers or computerprocessors. The code modules may be stored on any type of non-transitorycomputer-readable medium or computer storage device, such as harddrives, solid state memory, optical disc, and/or the like. The processesand algorithms may be implemented partially or wholly inapplication-specific circuitry. The results of the disclosed processesand process steps may be stored, persistently or otherwise, in any typeof non-transitory computer storage such as, e.g., volatile ornon-volatile storage.

The various features and processes described above may be usedindependently of one another, or may be combined in various ways. Allpossible combinations and subcombinations are intended to fall withinthe scope of this disclosure. In addition, certain method or processblocks may be omitted in some implementations. The methods and processesdescribed herein are also not limited to any particular sequence, andthe blocks or states relating thereto can be performed in othersequences that are appropriate. For example, described blocks or statesmay be performed in an order other than that specifically disclosed, ormultiple blocks or states may be combined in a single block or state.The example blocks or states may be performed in serial, in parallel, orin some other manner. Blocks or states may be added to or removed fromthe disclosed example embodiments. The example systems and componentsdescribed herein may be configured differently than described. Forexample, elements may be added to, removed from, or rearranged comparedto the disclosed example embodiments.

While certain example embodiments have been described, these embodimentshave been presented by way of example only, and are not intended tolimit the scope of the inventions disclosed herein. Thus, nothing in theforegoing description is intended to imply that any particular feature,characteristic, step, module, or block is necessary or indispensable.Indeed, the novel methods and systems described herein may be embodiedin a variety of other forms; furthermore, various omissions,substitutions and changes in the form of the methods and systemsdescribed herein may be made without departing from the spirit of theinventions disclosed herein. The accompanying claims and theirequivalents are intended to cover such forms or modifications as wouldfall within the scope and spirit of certain of the inventions disclosedherein.

What is claimed is:
 1. A method for monitoring a patient andnon-invasively determining a microcirculation state at an eyelid of thepatient, the method comprising: receiving, from a non-invasivephysiological sensor, a signal responsive to light of at least a firstwavelength and a second wavelength that is transmitted by thenon-invasive physiological sensor and detected by the non-invasivephysiological sensor after the light interacts with tissue of an eyelidof a patient; processing the signal to determine at least: a firstparameter indicative of a measure of perfusion of the tissue of theeyelid of the patient, and a second parameter responsive to at least aratio of the detected light at the first wavelength and the secondwavelength; determining a relationship between the first parameter andthe second parameter; comparing the determined relationship with atleast some of a plurality of stored relationships corresponding to oneor more microcirculation states; and determining a microcirculationstate at the eyelid based at least in part on the comparing thedetermined relationship with the at least some of the plurality ofstored relationships.
 2. The method of claim 1, wherein the secondparameter comprises oxygen saturation and the first parameter comprisesa perfusion index.
 3. The method of claim 1, wherein the plurality ofstored relationships comprises previously determined and storedrelationships between first parameters and second parameters.
 4. Themethod of claim 1, wherein at least some of the plurality of storedrelationships correspond to an at least partially blockedmicrocirculation condition.
 5. The method of claim 1, wherein at leastsome of the plurality of stored relationships correspond to an unblockedmicrocirculation condition.
 6. The method of claim 1, wherein when thecomparing indicates that the determined relationship is similar to atleast one of the plurality of stored relationships, wherein the at leastone of the plurality of stored relationships corresponds to an at leastpartially blocked microcirculation condition.
 7. The method of claim 1,wherein the microcirculation state at the eyelid comprises an at leastpartially blocked microcirculation state in at least a portion of bloodvessels at the eyelid.
 8. The method of claim 1, further comprisingproviding an electronic microcirculation condition warning.
 9. Themethod of claim 1, causing the non-invasive physiological sensor totransmit at least a portion of the light at a wavelength that isdifferent from the first wavelength and the second wavelength.
 10. Themethod of claim 1, applying an offset to at least one of the firstparameter or the second parameter to compensate for the microcirculationstate at the eyelid.
 11. A patient monitor, comprising: a sensorinterface configured to receive a signal from a physiological sensor,wherein the physiological sensor is configured to transmit light of atleast a first wavelength and a second wavelength into tissue of aneyelid of a patient and to detect the light after it interacts with thetissue of the eyelid of the patient, wherein the signal is responsive tothe detected light; and one or more processors configured to: determinea first parameter indicative of a measure of perfusion of the tissue ofthe eyelid of the patient and a second parameter responsive to at leasta ratio of the detected light at the first wavelength and the secondwavelength, determine a relationship between the first parameter and thesecond parameter, compare the determined relationship with at least someof a plurality of previously determined relationships corresponding toone or more microcirculation states, and determine a microcirculationstate at the eyelid based at least in part on the comparison of thedetermined relationship with the at least some of the plurality ofpreviously determined relationships.
 12. The patient monitor of claim11, further comprising a memory storing the plurality of previouslydetermined relationships, wherein the plurality of previously determinedrelationships comprise relationships between previously determined firstparameters and previously determined second parameters.
 13. The patientmonitor of claim 11, wherein the second parameter comprises oxygensaturation and the first parameter comprises a perfusion index.
 14. Thepatient monitor of claim 11, wherein at least some of the plurality ofpreviously determined relationships correspond to an at least partiallyblocked microcirculation condition.
 15. The patient monitor of claim 11,wherein at least some of the plurality of previously determinedrelationships correspond to an unblocked microcirculation condition. 16.The patient monitor of claim 11, wherein the comparison indicates thatthe determined relationship is similar to at least one of the previouslydetermined relationships, wherein the at least one of the previouslydetermined relationships corresponds to an at least partially blockedmicrocirculation condition.
 17. The patient monitor of claim 11, whereinthe microcirculation state at the eyelid comprises an at least partiallyblocked microcirculation state in at least a portion of blood vessels atthe eyelid.
 18. The patient monitor of claim 11, wherein the processoris further configured to provide an electronic microcirculationcondition warning.
 19. The patient monitor of claim 11, wherein theprocessor is further configured to cause the physiological sensor totransmit at least a portion of the light at a wavelength that isdifferent from the first wavelength and the second wavelength.
 20. Thepatient monitor of claim 11, wherein the processor is further configuredto apply an offset to at least one of the first parameter or the secondparameter to compensate for the microcirculation state at the eyelid.21. The patient monitor of claim 11, wherein the first wavelengthcomprises a red wavelength and the second wavelength comprises aninfrared wavelength.